Published in Vision Therapy

What New Grads Need to Know About Strabismus

This is editorially independent content
3 min read

As a new grad, patients with strabismus can be intimidating despite all of your clinical education. Here are the basics to handling these patients.

What New Grads Need to Know About Strabismus

As a new grad, you should feel like you have a well-rounded education and are prepared for anything that walks through your door.

However, there are always going to be a few things that make you a bit uncomfortable. I often hear from my colleagues that don't deal with binocular vision issues on a daily basis that "strabismic patients make them nervous."
This review will help remind you of the most important aspects to identify in your patients with strabismus so that you can discuss appropriate treatment options with your patient, even if you don't provide them.

1. Case History

This is by far the most important aspect of learning about the patient and the potential etiology of the strabismus.
You want to ask the following questions:
  • Onset – this is a really important question; if it is new onset in an adult, you will want to rule out a systemic etiology.
  • Presence of diplopia, ‘tired eyes’ or other symptoms that might tip you off that they have an issue.
  • Systemic health (hypertension, diabetes, etc…)
  • Family history
  • Any prior treatment

2. Visual Acuity

Test this at distance and near.
If amblyopia is also present, remember to test both single letter acuity vs. whole line.

3. Cover Test

This determines the type, magnitude and constancy of the deviation.
Start with unilateral cover test then move to alternating. If you have the equipment you can measure it with a prism bar... if not, make an estimation.

4. Level of Stereopsis

If you have the proper equipment, test for level of stereopsis as this will give you a good indication of how your patient is functioning.
This includes Worth 4 Dot for presence of flat fusion, Wirt Circles (local stereo) and RDS (global stereo).

5. Complete your regular "eye doctor stuff"

This includes a refraction to achieve the best corrected visual acuity. Additionally, a slit lamp exam and dilation should be completed to rule out any pathological etiology.
With this information you'll be able to discuss with your patients what the treatment options are and which is best suited for them.

Treatment Options Can Include:

1) Compensatory prism
For example: patients with divergence insufficiency or vertical deviations often find a lot of relief with a little bit of prism in their glasses. Determining the amount of prism is a matter of the size of the deviation, the patient's fusional ranges as well as their sensitivity.
2) Referral for vision therapy or surgery (if warranted)
Make sure you know which of your colleagues perform vision therapy so you can make the appropriate referral!
3) Monitoring
Sometimes if the patient is happy and is functioning just fine, you can choose to just monitor them.

Want more tips on binocular vision disorders? Check out our downloadable study guide!

Check out these COVD Resources:

  • Learn what COVD has to offer students and residents!
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Miki Lyn Zilnicki, OD, FCOVD
About Miki Lyn Zilnicki, OD, FCOVD

Miki Lyn Zilnicki, O.D. graduated with honors from the SUNY College of Optometry in New York, receiving the VSP Excellence in Primary Care and Excellence in Vision Therapy awards. She then continued her education by completing a residency in vision therapy and rehabilitation with Dr. Barry Tannen, OD.

She has extensive experience in family eye care with a specialty and passion for pediatrics, vision training, and neuro-rehabilitation with traumatic brain injury patients. With her partner, she owns Twin Forks Optometry, a specialty care private practice with a focus on vision therapy, rehabilitation, pediatrics, and low vision on the Eastern End of Long Island. In her spare time, she loves cooking and working on the farm with her fiancé.

Miki Lyn Zilnicki, OD, FCOVD
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